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GASTROINTESTINAL CARE CONSULTANTS, P.A.

MADHUKAR KAW, M.D.*

12121 RICHMOND AVENUE, SUITE 424, HOUSTON, TEXAS 77082

TEL:(832) 379-8603 FAX:(832) 379-1928

I hereby authorize Gastrointestinal Care Consultants, P.A. to charge my credit

card.

Circle type of credit card                       Visa                                  MasterCard

                                                           American Express              Discover

Amount:$_____________

Name as it appears on the card:_______________________________________

Card number:________________________ Expiration date:_____________

CVV:_______________________________

Your signature:_____________________________________________